1. Osteopathic Manipulation for Acute Otitis Media in the Pediatric Population
American College of Osteopathic Pediatricians
Kate Ruda Wessell, DO
Pediatric Resident
Rainbow Babies and Children’s Hospital
PGY-1
January 23, 2011

2. Ear Anatomy

3. Normal TM

4. Ear Anatomy
Outer Ear: Pinna, External Auditory Meatus, Outside of Tympanic Membrane
Middle Ear: Inside of Tympanic Membrane, 3 ossicles; Malleus, incus, and stapes and Eustachian Tube
Inner Ear: Cochlea, vestibule, and semi-circular canals

5. Otitis Media Inflammation of the Middle Ear
Location between the tympanic membrane and the inner ear including eustachian tube
Most frequent diagnosis in sick children in U.S.
Viral, bacterial, fungal:
-most often viral and self-limited
-bacterial causes include: #1 Streptococcus pneumoniae, nontypeable Haemophilus influenzae, and Moraxella catarrhalis
Signs/Symptoms
-discomfort, “popping”, pressure
Diagnosis:
-visualization of the TM, tympanic insufflator

6. Progression of the AOM
At an anatomic level, the tissues surrounding the Eustachian tube swell due to an URI, allergies, or dysfunction of the tubes. The Eustachian tube remains blocked most of the time. The air present in the middle ear is slowly absorbed into the surrounding tissues.
A strong negative pressure creates a vacuum in the middle ear, and eventually the vacuum reaches a point where fluid from the surrounding tissues accumulates in the middle ear. The fluid may become infected by dormant bacteria behind the TM

7. Kids > Adults. Why? The answer is simple. Shorter Eustachian Tubes
-10mm in infancy to 18mm in adulthood
A more horizontal angle of the Eustachian Tubes
-10 degrees to horizontal in infancy to 45 degrees in adulthood
60-80% of infants have at least 1 episode of AOM by age 1 year
80-90% by age 2 to 3 years

8. Risk Factors for AOM
Opportunity for Patient Education for the General Practitioner
Breast Feeding for at least 3 months decreases risk
Tobacco smoke and air pollution increases risk
Pacifier use increases incidence
Day care attendance raises the incidence

9. Otitis Media Treatments
Observation and Self-Limitation: based on diagnostic certainty, age, illness severity, and assurance of follow- up
Pain Remedies: topical agents (Auralgan), oral agents
Antihistamines, decongestants, steroids
Antibiotics
OMT
Tympanostomy Tubes

10. Treatment: Antibiotics
Amoxicillin mg/kg/day divided BID for 5-7 days for episodes in most children 6 yrs of age or older
Younger children and children with underlying medical conditions, craniofacial abnormalities, chronic or recurrent otitis media, or perforatoin of the tympanic membrane should receive a 10 day course
Persistent middle ear effusion for 2-3 months after therapy for AOM is expected and does not require routine retreatment
If effusion lasts greater than 3 months, tx for days may be considered
American Academy of Pediatrics “Red Book” 2009 Report of the Committee of Infectious Disease

11. Treatment: OMT Techniques
Galbreath Maneuver first described in 1929 by William Otis Galbreath, DO
Galbreath Maneuver: simple mandibular manipulation, the eustachian tube is made to open and close in a "pumping action" that allows the ear to drain accumulated fluid more effectively
Auricular Drainage Technique

12. Specifics of the Galbreath Maneuver
The pediatric patient should be lying his or her back
The physician places one hand on the chin, with thumb and forefinger resting along the lower jawbone. The other hand is placed on the forehead to hold the patient’s head in place.
As the child opens his/her mouth, the physician gently moves the lower jaw to the side away from the ear with AOM and holds it there for three to five seconds before releasing the jaw. The physician then repeats this maneuver three times.

13. Galbreath Technique

14. Auricular Drainage Technique
This technique also requires the pediatric patient to lie on his or her back
The physician forms a “V” by separating their middle and ring fingers on the hand that is closer to the child’s feet. Placing the ear with AOM in the base of this “V” the physician places his or her other hand on the opposite side of the child’s head to provide support. The physician then gently but firmly massages the infected ear in a clockwise motion, then reverses direction, massaging the infected ear in a counter-clockwise direction.

15. Auricular Drainage

16. Treatment: Tympanostomy Tubes
Generally considered when patients have more than 3 episodes of acute otitis media in 6 month or 4 in a year associated with an effusion
Reduces recurrence rates in the 6 months after placement

17. Evidenced Based Medicine
Case Study: 14 mo. old female with previous history of AOM tx’d with abx of amox 10 day course, and repeat abx for incomplete resolution. She presents with temp 102.8, pulse 118, RR 24, nose and pharynx erythematous and edematous. Right TM bulging, nonmovable with pneumatic otoscopy. Script for abx written and Galbreath technique in office. Within 30min of tx, child’s temp reduced to 99.2, and PE revealed decrease in erythema and edema of TM. Patient completed course of abx and Galbreath Technique 2 x daily. Whenever symptoms revisited; mother performed Galbreath, and pt. was not placed on abx since.
JAOA Vol 100 No 10 October 2000 Pratt-Harrington Review Article

18. Evidenced Based Medicine
Study Design:Pilot cohort study with 1 year posttreatment follow up
Subjects:Volunteer sample of pediatric patients ranging in age from 7mo to 3 yrs with a history of recurrent otitis media (n=8)
Intervention:For 3 weeks all subjects received weekly osteopathic structural exams and OMT; concurrently with trandional medical management.
Results: 5 (62.5%) had no recurrence of symptoms. One had a bulging TM, one had 4 more episodes of O.M., and one underwent surgery after recurrence at 6 weeks posttreatment. Closer analysis of the posttreatment course of the last two subjects indicates that there may have been a clinically significant decrease in morbidity for a period of time after intervention.

19. Evidenced Based Medicine
Conclusion:The study indicates that OMT may change the progression of recurrent AOM. There is a need for additional research in this area.
JAOA Vol 106 No 06 June 2006 Osteopathic Evaluation and Manipulative Treatment in Reducing the Morbidity of Otitis Media: A pilot study. Degenhardt, Kuchera pgs

20. Hands On: Time to Practice
Landmarks
Sympathetic Innervation
Order of Treatment to maximize technique efficacy:
-Stretching
-Myofascial Release of Restrictions/Choke Points
-Galbreath Technique
-Auricular Drainage
-Lymphatic Pump

21. 1. 2.
LANDMARKS
Locate the Ear of Your Patient
Imagine the Inner Ear Anatomy
Imagine the Lymphatic System Surrounding the Ear Anatomy 3.

22. Innervation Table EENT Organ/System Parasympathetic Sympathetic
Ant. Chapman's
Post. Chapman's
EENT
Cr Nerves (III, VII, IX, X)
T1-T4
T1-4, 2nd ICS
Suboccipital
Heart
Vagus (CN X)
T1-4 on L, T2-3
T3 sp process
Respiratory
T2-T7
3rd & 4th ICS
T3-5 sp process
Esophagus
T2-T8
---
Foregut
T5-T9 (Greater Splanchnic)
Stomach
5th-6th ICS on L
T6-7 on L
Liver
Rib 5 on R
T5-6
Gallbladder
Rib 6 on R T6
Spleen
Rib 7 on L T7
Pancreas
T5-T9 (Greater Splanchnic), T9-T12 (Lesser Splanchnic)
Rib 7 on R
Midgut
Thoracic Splanchnics (Lesser)
Small Intestine
T9-T11 (Lesser Splanchnic)
Ribs 9-11
T8-10
Appendix
 T12
Tip of 12th Rib
T11-12 on R
Hindgut
Pelvic Splanchnics (S2-4)
Lumbar (Least) Splanchnics
Ascending Colon
 Vagus (CN X)
T9-T11 (Lesser Splanchnic)
R hip
T10-11
Transverse Colon
Near Knees
Descending Colon
Pelvic Splanchnic (S2-4)
Least Splanchnic
L hip
T12-L2
Colon & Rectum
Pelvic Splanchnics (S2-4)
T8-L2

23. STRETCHING

24. MYOFASCIAL RELEASE

25. GALBREATH TECHNIQUE

26. AURICULAR DRAINAGE

27. LYMPHATIC PUMP

28. Question 1: What is the most common bacterial cause of AOM?
Haemophilus Influenza
Streptococcus pneumonia
Moraxella catarrhalis
Pseudomonas aeruginosa

29. Question 2:
What is the most sensitive diagnostic tool for diagnosing AOM?
Visualization of TM with otoscope
Pneumatic otoscopy
A child tugging at their ears
Fever and a child tugging at their ears

30. Question 3:
What is the appropriate order to complete OMT treatments to increase the efficacy of OMT to treat AOM?
A. Galbreath Technique, Stretching, Restriction Reduction, Auricular Drainage, Lymphatic Pump
B. Auricular Drainage, Galbreath Technique, Stretching, Restriction Reduction
C. Stretching, Restriction Reduction, Galbreath Technique, Auricular Drainage, Lymphatic Pump
D. Lymphatic Pump, Galbreath Technique, Auricular Drainage, Stretching, Restriction Reduction

31. Summary Ear Anatomy Otitis Media: causes, diagnosis, treatment
OMT Techniques
Evidenced Based Medicine
Potential Areas to Continue to Develop Osteopathic Principles and Practice regarding Otitis Media
-blinded studies with larger cohorts are necessary to determine the effectiveness of this tx modality in pediatric patients

32. SPECIAL THANKS TO MY PATIENTS: HAYDEN AND MAYCEE

33. References
Acess Medicine: Current Medical Diagnosis and Treatment: Chapter 8. Ear, Nose, and Throat Disorders. “Acute Otitis Media”
Gunasekera H et al. Management of children with otitis media: a summary of evidence from recent systematic reviews. J Pediatric Child Health Oct; 45 (10):
JAOA Vol 100. No 10. October “Galbreath Technique: a manipulative treatment for Otitis Media Revisited” pgs
JAOA Vol 106 No 06 June “Osteopathic Evaluation and Manipulative Treatment in Reducing the Morbidity of Otitis Media: A pilot study.” Degenhardt, Kuchera pgs
Red Book: 2009 Report of the Committee on Infectious Disease. American Academy of Pediatrics “Otitis Media” page 741.
UpToDate: Acute Otitis Media in Children

34. Certificate of Completion
I, _________________________, successfully completed the Pediatric OMT Module on __ __ 20__
Signatures:
Pediatric Resident ____________________
Pediatric Residency Director____________
( Please print and give to program director.)